Diagnosis guidelines

BWC relies on MCOs to gather pertinent medical documentation from all treating providers

BWC relies on managed care organizations (MCOs) to gather pertinent medical documentation from all treating providers to make a decision about claim allowance. To perform this function efficiently, BWC, MCOs and providers need to know the guidelines and criteria. BWC uses the medical documentation contained in the claim file as critical evidence in making the decision. This evidence becomes even more critical when the claim is set for a hearing.

BWC developed a reference, MEDD Master Spreadsheet to provide criteria for diagnosis determination/coding decisions between BWC and MCOs. The spreadsheet lists the International Classification of Diseases (ICD) code with the diagnosis narrative description, subjective and objective exam findings, diagnostic tests (if applicable) and findings for diagnosis substantiation.

This spreadsheet should be used as a reference tool. Do not use it to direct medical care or to authorize medical treatment.